The consumer quality index anthroposophic

Koster et al. BMC Health Services Research 2014, 14:148
http://www.biomedcentral.com/1472-6963/14/148
RESEARCH ARTICLE
Open Access
The consumer quality index anthroposophic
healthcare: a construction and validation study
Evi B Koster1*, Rob RS Ong1, Rachel Heybroek1, Diana MJ Delnoij2 and Erik W Baars1
Abstract
Background: Accounting for the patients’ perspective on quality of care has become increasingly important in the
development of Evidence Based Medicine as well as in governmental policies. In the Netherlands the Consumer
Quality (CQ) Index has been developed to measure the quality of care from the patients’ perspective in different
healthcare sectors in a standardized manner. Although the scientific accountability of anthroposophic healthcare as
a form of integrative medicine is growing, patient experiences with anthroposophic healthcare have not been
measured systematically. In addition, the specific anthroposophic aspects are not measured by means of existing
CQ Indexes. To enable accountability of quality of the anthroposophic healthcare from the patients’ perspective the
aim of this study is the construction and validation of a CQ Index for anthroposophic healthcare.
Method: Construction in three phases: Phase 1. Determining anthroposophic quality aspects: literature study and focus
groups. Phase 2. Adding new questions and validating the new questionnaire. Research population: random sample
from 7910 patients of 22 anthroposophic GPs. Data collection: survey, mixed mode by means of the Dillman method.
Measuring instrument: experience questionnaire: CQ Index General Practice (56 items), added with 27 new
anthroposophic items added and an item-importance questionnaire (anthroposophic items only). Statistical analyses:
Factor analysis, scale construction, internal consistency (Chronbach’s Alpha), inter-item-correlation, discriminative ability
(Intra Class Correlation) and inter-factor-correlations. Phase 3. Modulation and selection of new questions based on
results. Criteria of retaining items: general: a limited amount of items, statistical: part of a reliable scale and
inter-item-correlation <0,7, and theoretical.
Results: Phase 1. 27 anthroposophic items. Phase 2. Two new anthroposophic scales: Scale AntroposophicTreatmentGP:
seven items, Alpha=0,832, ICC=4,2 Inter-factor-correlation with existing GP-scales range from r=0,24 (Accessibility) to
r=0,56 (TailoredCare). Scale InteractionalStyleGP: five items, Alpha=0,810, ICC=5,8, Inter-factor-correlation with existing
GP-scales range from r=0,32 (Accessibility) to r=0,76 (TailoredCare). Inter-factor-correlation between new scales: r=0,50.
Phase 3: Adding both scales and four single items. Removing eleven items and reformulating two items.
Conclusion: The CQ Index Anthroposophic Healthcare measures patient experiences with anthroposophic GP’s validly
and reliably. Regarding the inter-factor-correlations anthroposophic quality aspects from the patients’ perspective are
mostly associated with individually tailored care and patient centeredness.
Keywords: Quality of care, Patient experiences, CQ-index, Anthroposophic healthcare, Validation of measuring
instrument, Psychometric quality, Discriminating ability, Patient-centered care
* Correspondence: [email protected]
1
Professorship Anthroposophic Healthcare, University of Applied Sciences
Leiden, Zernikedreef 11, Leiden 2333 CK, The Netherlands
Full list of author information is available at the end of the article
© 2014 Koster et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.
Koster et al. BMC Health Services Research 2014, 14:148
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Background
The Evidence Based Medicine (EBM) development that
started in the nineties of the 20th century has influenced
healthcare to a large extent. The main aim of EBM is to
improve the quality of healthcare for the individual patient, based on the best evidence available [1].
In association with other developments such as New
Public Management from the eighties of the 20th century
and subsequently accountability of public finance, there
is an increasing demand for scientific and societal accountability of the quality of healthcare [2].
According to the Institute of Medicine [3] quality of care
is a multidimensional concept consisting of at least six domains: effectiveness, safety, patient centeredness, timeliness, efficiency and equitably.
In the last two decades one of these domains, patientcentred care, has become increasingly important in relation
to the evaluation of the quality of healthcare [4,5]. Patientcentred care represents a humanistic, bio-psychosocial
perspective in healthcare, with a strong emphasis on communication, patient participation in clinical decision making, forming a therapeutic alliance and sharing power and
responsibility [6].
Various instruments have been developed in order to
measure patients’ experiences with patient centeredness,
for instance the instruments known as CAHPS (Consumer Assessment of Healthcare Providers and Systems),
or the instruments developed by the Picker Institute, and
the Consumer Quality Index [7,8].
In 2006, the Dutch Ministry of Health promoted the
Consumer Quality (CQ-) Index as the instrument to measure patient experiences with healthcare [9,10]. Since then
the CQ-Index has been developed in a way that different
healthcare services and providers can be measured within
the same systematic structure, in order to be able to compare these experiences [8,11].
Currently, several CQ-Indexes have been developed to
measure patient experiences with for example: asthma
care [12], physiotherapy, hospital specialist care [13],
COPD care [14] and general practice [15].
The construction and validation process of a new CQindex is protocolled by the former Dutch foundation
CKZ (Centre for client experiences in healthcare). [11]
Important parts of this protocol are the formulation of
the items and the standardized answer categories, the
method of data collection and the statistical analyses.
Anthroposophic healthcare
Since ideally patient experiences with all areas of healthcare have to be measured, this also is of relevance for
anthroposophic healthcare (AH). AH is a form of integrative medicine (IM) that is provided to a small part of
the Dutch population (estimation: 200 000 clients) in 80
general practitioner practices [16].
Page 2 of 12
AH emphasizes the relationship between the body, the
soul and the mind as well as lifestyle, meaning in life
and environmental factors with regard to health and disease. It focuses on the support and active stimulation of
physiological self-healing and the self-regulating ability
of people. Additional therapies based on the study of
anthroposophic humanities, the development and use of
natural medicines and a reticent use of conventional
chemical medication play an important role within AH.
A frequently mentioned and highly appreciated characteristic is the attention to antropos, the human being. In
practice it means a professional orientation to the individual, an equal relationship between patient and healthcare provider and much time and attention for the
patient [16], or in other words: patient-centred care.
AH is strongly organised internationally. This integrative form of healthcare is currently studied and taught at
various universities in Europe and ambulatory and clinically practiced in eighty countries worldwide [17].
AH encompasses multiple sectors: general practice,
occupational medicine, primary school doctoring, child
welfare centres (CWC) clinical specialists, psychiatry,
special needs care, and a large amount of paramedic sectors such as physiotherapy, art therapy, eurhythmy therapy and psychotherapy. The GPs work independently
and often closely together with these therapeutic disciplines in integrative healthcare centres.
Although the quality and the quantity of the scientific
underpinning of AH is growing [17-20], it still suffers from
a lack of acknowledgement within conventional healthcare. In the Netherlands as well as internationally large
groups of people have good experiences with anthroposophic healthcare [17,21,22].
Nonetheless, up until now, patient experiences with
anthroposophic healthcare have not been measured systematically. To enable accountability of quality of AH
from the patients’ perspective, the aim of this study is to
develop a standardized instrument to measure patients’
experiences with AH objectively and systematically.
This instrument will generate feedback information
about patient experiences, which can be used to monitor
and improve the quality of AH. The instrument will meet
the increased demand for quality assurance of (anthroposophic) healthcare in general and it will contribute to the
scientific underpinning and accountability of AH.
The present study focuses on investigating specific
anthroposophic aspects of quality of care; the reliability,
factorial structure and validity of the CQ-Index Anthroposophic Healthcare; the experiences with these anthroposophic aspects of healthcare in a group of patients at
anthroposophic GP practices; and designing a final version
of the CQ-Index questionnaire. The development of the
CQ-index AH combined the development of a measuring
instrument for GP care with a measuring instrument for a
Koster et al. BMC Health Services Research 2014, 14:148
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broader spectrum of AH therapies. This article focuses on
the development of the CQ-index AH for GP care only.
The overall research question was: How can quality of
anthroposophic healthcare be measured from the patients’ perspective? More specifically: Which aspects of
quality of care are important from the perspective of patients of anthroposophic GP’s? How can these aspects of
care be measured as individual items in a valid and reliable way? Which items are part of a valid coherent scale
and should be retained? What are patients’ experiences
of these aspects of care?
Methods
The CQ-Index systematic consists of an experience
questionnaire and an item-importance questionnaire
[11]. According to the CKZ-guidelines the construction
of the CQI-AH consisted of three phases. Phase one
concerned the determination of the aspects of quality of
care that are important from the perspective of patients
of anthroposophic GP’s and the construction of ‘anthroposophic questions’. Phase two concerned the adding of
new questions to the existing CQ-Index General Practice
[15], conducting a survey involving a sample of nearly
8000 patients of the population of anthroposophic GPs
and validating the new questionnaire. Phase three concerned the modulating and selection of new questions
based on the results in the previous phases.
Ethics statement
Regarding research ethics it is important to mention
under Dutch legislation, which is laid down in the Medical Research Involving Human Subjects Act [23], this
study is not subject to approval of an ethics commission.
The Declaration of Helsinki does not apply on this study,
because it is not medical research, but social science.
The patients’ experiences are used to evaluate the performance and service of doctors. There is no medical
data involved.
However, the study is carried out according to protocol of the former foundation CKZ (Centre for patient
experiences in healthcare) [24]. The protocol is written
down in the Handbook CQI development [11]. All necessary research ethics are covered within this protocol and
the protocol was tested on it. The protocol is also fully
in line with the legislation of the Dutch DPA (Data Protection Authority). The researchers followed this protocol in detail.
Phase 1: determining anthroposophic aspects
In order to determine what the anthroposophic aspects
of GP care are, the CKZ-guidelines prescribe literature
review and focus groups and/or interviews with experts.
Rather than having both focus groups and interviews it
was chosen to invite all participants in the focus group
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process. In this way patients and professionals could actually have a discussion on quality aspects together.
The literature was reviewed and three focus groups
were organised.
Literature study
For the literature study a database search of Pubmed, Google Scholar, the database of the international anthroposophic Medical Section [25] and the internet in general was
executed. The search terms were (a combination of): ‘quality of care’, ‘anthroposophy’, ‘anthroposophic healthcare’ ‘patients’ perspective’. In addition, the Dutch anthroposophic
occupational associations and the Dutch anthroposophic
healthcare institutions were asked for client questionnaires
with specific anthroposophic items. Finally, the Dutch patient organisation for AH, Antroposana, was consulted for
literature on the subject of quality aspects of anthroposophic care from the perspective of their members.
Focus groups
Because of the wider context of the study regarding the
broad spectrum of anthroposophic therapies both anthroposophic GP care and anthroposophic therapist care were
discussed in the focus groups. Regarding the composition
of the focus groups the guidelines of the CKZ were
followed. A minimum of 6 participants was compulsory.
In the first focus group (with three patients, three
healthcare professionals, and one chairman) specific domains of anthroposophic experiences were determined
and corresponding conceptual questions were formulated.
The second focus group was an enlargement of the first
focus group. A broad spectrum of anthroposophic therapists (13), doctors (4) and several patients (8) gave their
feedback on the conceptual domains and questions that
were constructed as a result of the first focus group. To
minimalize group- and information management issues
the communication in the second focus group went
through email. In the third focus group (with two patients,
two healthcare professionals, and two researchers) the
feedback from the second focus group was discussed. All
the professional views were in the end discussed with the
patients’ representations.
The patients were recruited from the Dutch patient
organisation for AH, Antroposana. In total nine different
patients were consulted for the construction of the questionnaire, two of them were present at all focus groups.
The doctors and therapists were recruited from their
anthroposophic occupational associations. All healthcare
professionals had a working experience of a minimum of
5 years. In the consensus process with the members of
the focus group and the anthroposophic patient organisation additional items were formulated. After that they
were tested cognitively. The questionnaire was sent to
13 members of the anthroposophic patient organisation.
Koster et al. BMC Health Services Research 2014, 14:148
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They were asked if the questions and the structure of
the questionnaire were understandable. After integrating
the criticisms the questions were added to the existing
CQ-Index General Practice [15] and a new questionnaire
was constructed.
Phase 2: validation of the CQ-index AH
Research population
The new questionnaire was tested in a survey involving a
patient population among 22 Dutch anthroposophic GPs.
(Total population: 29 341 patients) Following the guidelines
of the CKZ [11] two random samples were taken. One random sample consisted of 6910 patients of 22 anthroposophic GP practices (range: 250-475 per practice).
According to the guidelines 20 practices were needed.
It was chosen to include two spare practices.
Following the recommendations of the pilot study
CQ-Index GP [15] only patients aged 18 years and older
who visited their GP in the last year were included. They
received the newly constructed questionnaire called the
experience questionnaire. This questionnaire was to be
validated. After the first sample a smaller random sample of 1000 patients (50 per practice) was taken from 20
of the original 22 anthroposophic GP practices. In this
sample no spare practices were needed. These patients
received the item-importance questionnaire. This questionnaire resulted in an importance rating per item. This
rating was part of the criteria for the item inclusion in
the factor-analyses of the experience questionnaire. It
was chosen to send both questionnaires to different
samples in order not to burden the respondents with
more than one questionnaire.
The CKZ-guidelines describe that the samples need to
be representative in comparison to the population. This
is checked for each GP practice individually while taking
the samples.
Data collection
The data collection was primarily accomplished online.
This was also a recommendation of the pilot study CQIndex GP [15], in order to be able to cut costs and save
paper. Respondents received an invitation by mail from
their GP practice with an Internet link and a login. A supplement in English, Turkish and Arabic was attached.
People who didn’t want or had difficulties responding online could ask for a paper version of the questionnaire.
Two weeks after the first invitation the whole sample
received a thank-you/reminder postcard and four weeks
after the first invitation only the non-responders received a reminder invitation containing the Internet link
and the login again. The data collection took place in accordance with the privacy legislation of the Dutch DPA
(Data Protection Authority).
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Measuring instruments
The experience questionnaire measured patients’ experiences with quality of care. The questionnaire contained
83 items, of which 56 from the existing CQ-Index GP
and 27 new anthroposophic items. The response options
of the majority (69) of the items were: never (1), sometimes (2), usually (3) and always (4). Six items had response options yes and no. One item was a global rating
of the GP practice, with response options from 0 (worst
possible) to 10 (best possible) and one item was a net
promotor score. Seven items had other response options
and two items had open answers.
The item-importance questionnaire contained the
same questions, only reformulated to ask about patients’
opinions of the importance of the 27 new anthroposophic questions.
The answer categories were: not important (1), quite
important (2), important (3) and very important (4). Finally, both questionnaires contained questions regarding
the background characteristics of the respondent.
Statistical analyses
Univariate and multivariate statistical analyses were
conducted in order to test the validity of the new items
and gather information needed to construct a new CQIndex AH.
Three consecutive factor analyses were performed to explore if the new items led to new factors: a first factor analysis to establish the factorial structure of the new items, a
second factor analysis to determine if these factors contributed to the factorial structure of the original questionnaire and the last factor analysis to test if additional
anthroposophic questions loaded on original factors. After
the construction the new scales were checked to confirm
that each of them didn’t consist of more than one factor.
The items were analysed individually before including
them in the factor analyses. The criteria for inclusion of
new items in the factor analyses were: comparable answerstructure, number of missing values (combined with the
answers ‘don’t know’ and ‘not applicable’), importance rating, inter-correlation of the answers of separate questions.
The discriminative ability was determined by means of
intra-class-correlation (ICC) scores of the new scales and
items.
Subsequently, the statistical quality of new scales (and
items) was tested by determining the intra-class-correlation
(ICC), factor loadings, item-total-correlation (ITC) and
Crohnbach’s alpha if item deleted. Also, inter-factorcorrelations between both new and original scales were
calculated.
Phase 3: modelling and selection of new items
In order to decide which items were to be enclosed in the
final measurement instrument, general, statistical and
Koster et al. BMC Health Services Research 2014, 14:148
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theoretical criteria were followed. The general criterion
was to only add a limited number of necessary items contributing to new reliable scales with additional value. The
statistical criteria were that items were part of a reliable
scale and had inter-item-correlation <0,7. The theoretical
criteria concerned the content of AH. The final decision
per item was made in dialogue with the Dutch anthroposophic GP’s occupational association and the Dutch
anthroposophic patient organisation.
Page 5 of 12
Results
(Table 1) 65% of the responders were female and 35%
were male. The mean age of the responders was 54 years
(sd = 15) (Table 2).
The responders are on average high educated. More than
55% had a HBO a [1] or university education. 78% considered his or her general health good to excellent. 14% had
used the possibility to answer the questionnaire on paper
instead of online. In comparison with the sample, women
responded more often (experience: p < 0,000, itemimportance: not significant) as well as people aged >45 years
(experience and item-importance: p < 0,000).
Phase 1: anthroposophic quality aspects
Literature study
Item analysis
The Dutch patient organisation for AH formulated their
quality criteria of AH in 9 domains: Autonomy, Treatment
attitude, Support, Therapy, Expertise, Information, Accommodation, Organisation, and Professional regulation [26].
The following validated questionnaires are used: CQIndex Huisartsenzorg Overdag [27], CQ-Index Kortdurende ambulante GGZ [28], Vragenlijst levenshouding (SOC
scale) [29], Levensvisie vragenlijst [30], Werkalliantie vragenlijst [31], IDQOL-16 [32] and Vragenlijst Jeugdthermometer [33]. Three non-validated questionnaires from three
healthcare centres were also used.
Focus groups
Specific aspects that are associated with anthroposophic
care mentioned in the focus groups are (amongst
others): Being heard as a human being; individually tailored care; attention to physiological self-healing; autonomy of the patient; deeper insight in one own health
problem; less side effects; body, soul and mind as a
unity; conscious integration of spirituality or view on life
within treatment; interdisciplinary cooperation; enough
time for the patient and possibility of choosing for conventional and/or anthroposophic treatment.
In the focus groups the following domains of AH have
been formulated: Practice/organisation, Cooperation between healthcare professionals, Life vision and spirituality,
Therapeutic relationship, Physiological self-healing, selfmanagement, Individually tailored care, Expertise and
insight, Structure of treatment and Healing Environment.
These domains led to the formulation of 27 additional
items. These items were added to the existing experiences questionnaire CQ-index GP and reformulated into
an item-importance questionnaire (only AH items).
Phase 2: validation of the CQ-index AH
Response rate
The experience questionnaire had a gross response rate of
35, 4% and a net response rate of 30, 6% (NGP = 2063)
(Table 1).
The item-importance questionnaire had a response
rate of respectively 35, 2% and 32, 2% (NIM = 315).
There were 4 items with high percentages (>50%) missing and no items with extreme skewness. 8 items had a
high inter-correlation (r > 0, 7) with one or more other
items. Table 3 shows details about the item analyses.
Table 4 shows the importance rating per item. There
were 11 items with a high importance rating (>3)
(Table 3 and 4)
Factor analyses
The first factor analysis showed a structure of three
components, (component one: items 43-49,71,77, component two: items 68,73,75-77,84 and component three:
items 68-70,83). The second factor analysis showed one
component with exclusively additional items (68,73,7577,84). The third factor analysis showed the impact of
the additional items on the old scales. Two existing
scales (Accessibility and Reception) didn’t change. One
additional item (43) loaded on the scale SocialHandlingGP. 10 items (43-49, 68, 71 and 77) loaded on the
scale CommunicationGP, and 8 items (43-49 and 71)
loaded on the scale TayloredCareGP. Also, the scale TayloredCareGP divided into three components. A fourth
factor analysis confirmed the newly constructed scales
and showed only minor shifts in factor loadings.
Scale construction
Finally, two new scales regarding AH were constructed.
The first scale contains items about the treatment attitude of the GP and the therapeutic relationship between
the GP and the patient. This scale is called InteractionalStyleGP. The second scale contains items concerning
the content of the anthroposophic approach within the
treatment from the GP. This scale is called AnthroposophicTreatment. Table 3 shows details about the item
analysis and factor analyses that were the basis of the
item selection regarding the new scales and Table 5
shows the final item content of the two scales
Psychometric quality
Both scales are sufficiently internally consistent (Cronbach’s Alpha > 0, 7) (Table 5).
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Table 1 Response analysis
NGP
Gross sample
% of net sample
% of gross response
NIM
6910
1000
Not registered at GP
100
20
No visit in last 12 months
75
-
Younger than 18
2
1
Net sample
6733
100%
979
Non response with notification
23
Recently died
4
-
4322
625
Non response without notification
Gross response
2384
Not completed questionnaires (digital)
35,4%
100%
281
345
2
-
2
-
Only therapist questionnaire
36
-
-
4
2063
The correlations between the existing and the new
scales vary strongly (Table 6). Both new scales have their
highest correlation with the existing TailoredCareGP scale
(AnthroposophicTreatment: r = 0, 56; InteractionalStyleGP: r = 0, 76). The correlation between the two new
GP scales is r = 0, 50. The AnthroposophicTreatment scale
has low to moderate correlations with all other scales.
The ICC values (InteractionalStyleGP: ICC=5,7;
AnthroposophicTreatment: ICC=4,2) demonstrate that
these scales are able to determine small though statistically significant differences between the GP practices.
CQ-index AH scores
The mean overall value for patients’ global rating of the
GP practices is 8,4 (range 0-10; sd=1,2).
Table 2 Sample and response: age and gender
Net sample
Net response
Experience
6733
2063
% male
38,9
34,8
% female
61,1
65,2
Age, mean
49,36
54,53
(SD)
(17,45)
(15,40)
% under 45 years
40,8
25,1
% 45 years and above
59,2
74,9
Item-importance
979
315
% male
38,1
35,9
% female
61,9
64,1
Age, mean
49,27
54,01
(SD)
(17,08)
(14,63)
% under 45 years
39,1
24,4
% 45 years and above
60,9
75,6
35,2%
26
Paper and digital
Net response
100%
9
Less than 50% of compulsory questions
Other
% of net sample
30,6%
86,4%
315
32,2%
The mean scale scores, following the answer categories, (range 1(never) - 4(always)) are: InteractionalStyleGP: 3,6; AnthroposophicTreatment: 3,1 (Table 5).
The mean scale scores equal the answer categories usually
and always.
The mean overall value and the mean scale scores
demonstrate an overall positive image of the anthroposophic GP care.
Phase 3: final questionnaire
The final questionnaire consists of the complete CQIndex GP added with two anthroposophic scales. The
scale InteractionalStyleGP contains five items. The scale
AnthroposophicTreatment contains seven items. Four
items remain singular items because of their importance
for AH. The complete final questionnaire is provided in
an additional file. (Additional file 1)
Discussion
In this study a CQ-index AH has been constructed and
tested among 2063 patients in 22 GP practices. The CQindex AH contains the complete CQ-Index General
Practice, two new anthroposophic scales and four singular items. The internal consistency of the two new scales
is sufficient and the discriminating ability of the two
new GP scales is small though statistically significant.
The results of the measurement of client experiences in
AH practices are positive. The mean scale scores demonstrate positive experiences with anthroposophic care. The
anthroposophic GP practices are valued with a mean of
8,4 on a scale from 0 to 10.
The recommendation to invite people to an online
questionnaire has been successfully brought in practice:
87% of the responders used the Internet. The general
Don’t
Not
Total
High inter-item Importance
Including in Factor loading Item-total
know (%) applicable (%) missings (%)
correlation
rating >3,0:+ factor analyses:
(factor)
correlation
[item]
or <2,5:+ or analysis 1
Additional theoretical
reason for including
or excluding
Practice
22. Ervoer u de inrichting van de wachtspreek/behandelkamer als positief op
uw welzijn?
10,1
12,2
-
-
Ex:-
2,2
+
+
0,746
2,1
+
+
0,782
+
+
0,743
(inside environment of practice building)
GP’s interactional style
43. Stelde uw huisarts u op uw gemak?
44. Had uw huisarts voldoende
begrip voor uw klacht of
aandoening?
0,764
In:-
0,724
In:-
0,766
Ex: item- reduction,
inter-item correlation
0,777
Ex: item- reduction,
inter-item correlation
0,776
In:-
0,611
In:-
0,548
In:-
(1)
(showing understanding)
45. Gaf uw huisarts u inzicht over de
achtergrond en mogelijke oorzaken van
uw klacht of aandoening?
2,5
[46]
(1)
(providing insight in background and causes)
6,8
50,5
59,2
[45,47]
+
0,718
3,5
[46]
+
0,756
(1)
(helping to cope with constraints)
47. Had uw huisarts aandacht voor de
eventuele gevolgen van uw
klacht/aandoening voor uw sociale leven?
(1)
(attention for social consequences)
48. Bood uw huisarts u de zorg die u
op dat moment nodig had?
2,3
+
+
0,783
12,5
+
+
0,690
(1)
(providing needed care)
49. Had uw huisarts een goede balans
tussen betrokkenheid en
professionele afstand?
In:-
(1)
(making comfortable)
46. Hielp uw huisarts u omgaan met
de ongemakken en beperkingen die de
klacht/aandoening met zich meebrengt?
0,711
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Table 3 Item analyses, factor analyses and item selection regarding new anthroposophic scales
10,4
(1)
(balanced attitude)
Treatment/intervention
(anthroposophic treatment options)
4,0
+
0,421
(2)
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68. Bent u door uw huisarts goed
geïnformeerd over de antroposofische
behandelingsmogelijkheden?
69. Heeft uw huisarts u vrij gelaten in
de keuze voor een reguliere en/of
antroposofische behandeling?
25,5
28,9
[70]
+
+
0,626
In: Medical–ethical value
0,620
Ex:-
0,631
Ex: Item reduction,
partly covered by
existing item 31
0,655
In:-
(3)
(free choice of treatment options)
70. Heeft uw huisarts u vrij gelaten in
de keuze voor chemische of natuurlijke
medicatie?
21,2
24,6
9,7
[69]
+
+
0,863
12,7
+
+
0,611
27,8
+
+
0,625
(3)
(free choice of type of medication)
71. Waren u en uw huisarts het eens over
hoe uw klacht of aandoening te behandelen?
(1)
(consensus about treatment)
73. Richtte uw huisarts de behandeling
(ook) op het ondersteunen van de
eigen herstelkrachten van uw lichaam?
0,844
24,6
(2)
(focus on physiological self-healing)
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Table 3 Item analyses, factor analyses and item selection regarding new anthroposophic scales (Continued)
Anthroposophic view
74. Kon u door de antroposofische
benadering beter begrijpen wat er
met u aan de hand was?
27,6
31,2
[78]
-
Ex:-
15,7
19,4
+
+
0,749
17,6
21,3
+
+
0,829
(provinding insight in situation)
75. Werd u door uw huisarts aangesproken
in uw eigen verantwoordelijkheid voor de
keuzes die u maakt met betrekking tot
uw gezondheid?
5,7
39,7
48,6
+
In:-
0,729
0,710
Ex: item reduction,
combination with 76
(2)
(support of GP)
78. Kon u door de antroposofische benadering
uw klacht/aandoening betekenis geven
binnen de samenhang van uw leven
en functioneren?
0,706
(2)
(patients’ active contribution)
77. Ondersteunde de arts u hierbij op
voor u belangrijke momenten?
In:-
(2)
(patients’ own responsibility)
76. Motiveerde de aanvullende
benadering u om zelf actief aan uw
gezondheidstoestand bij te dragen?
0,586
11,2
36,8
51,2
[74,79]
-
In: theoretical
importance
content AH
11,0
38,4
52,3
[78]
-
Ex:-
(giving meaning with daily life)
(support on personal growth)
Page 8 of 12
79. Ondersteunde de antroposofische
benadering u in uw persoonlijke
ontwikkeling als mens?
80. Bood de antroposofische benadering u
handvatten (of inspiratie) om uw
klachten/aandoening een spirituele
betekenis te geven?
10,5
40,5
54,1
-
-
Ex:-
(spiritual meaning)
Perceived treatment effect
83. Waren er bijwerkingen van de
behandeling?
21,4
25,7
24,0
28,2
+
0,436
+
0,663
In: theoretical and
scientific importance:
separate item.
0,567
In:-
(3)
(prevalence of side effects)
84.Beïnvloedde de behandeling de
kwaliteit van uw leven op een
positieve manier?
0,141
8
(1)
(influence on quality of life)
Separate items with other answer catagories
(no factor analyses)
67. Wat is de belangrijkste klacht of aandoening
waarvoor u de afgelopen 12 maanden in
behandeling bent geweest?
Koster et al. BMC Health Services Research 2014, 14:148
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Table 3 Item analyses, factor analyses and item selection regarding new anthroposophic scales (Continued)
Ex: item reduction, not
compulsory for
respondent
(main complaint/illness, open item)
72. Hoe bent u behandeld?
16,2
In: comparison between
AH and conventional
care
34,7
3,3
In: scientific importance
9,7
5,1
Ex: joined with 67
(way of treatment)
81. Heeft de antroposofische benadering u
verwachtingen gegeven ten aanzien van
het verbeteren van uw gezondheid?
(expectations of AH treatment)
82. Binnen welke termijn heeft u positief
effect van de behandeling ervaren?
85. Zo ja, kunt u aangeven waarom?
In: joined with 84
(If so, please explain why? open item)
Page 9 of 12
Koster et al. BMC Health Services Research 2014, 14:148
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Page 10 of 12
Table 4 Importance ratings
Items
Importance rating
Practice
22. (inside environment of practice building)
2,5
GP’s interactional style
43. (making comfortable)
3,1
44. (showing understanding)
3,4
45. (providing insight in background and causes)
3,4
46. (helping to cope with constraints)
3,0
47. (attention for social consequences)
2,8
48. (providing needed care)
3,4
49. (balanced attitude)
3,2
Treatment/intervention
68. (anthroposophic treatment options)
2,9
69. (free choice of treatment options)
3,1
70. (free choice of type of medication)
3.1
71. (consensus about treatment)
3,1
73. (focus on physiological self-healing)
3.2
Anthroposophic view
74. (providing insight in situation)
3,0
75. (patients’ own responsibility)
3,0
76. (patients’ active contribution)
3,1
77. (support of GP)
2,9
78. (giving meaning within daily life)
2,9
79. (support on personal growth)
2,7
80. (spiritual meaning)
2,1
Perceived treatment effect
83. (prevalence of side effects)
2,7
84. (influence on quality of life)
3,1
Separate items with other answer
catagories: no importance analysis
-
response was lower than expected, though the difference
between the gross and the net response was small. Due
to the digital data collection most of the questionnaires
(86, 4%) could be used for analysis.
It seems obvious to think that the relatively low response rate was related to the comprehension of the
added questions and the length of the questionnaire.
However, this does not show up from the number of
people who started, but did not finish the questionnaire. Also, there is hardly any difference in response
percentage between the relatively long experiences
questionnaire and the relatively short item-importance
questionnaire.
The most explicit characteristics of the responders are
the high percentage of higher education and the majority
being female and over 45 years of age. These characteristics differ only slightly from the international research
[17] about the socio-demographics of the users of AH.
Kienle [17] demonstrates that anthroposophic treatment
is used particularly by well-educated women aged between
30 and 50 years.
The adding of the two new scales demonstrates that it
is possible to measure patients’ experiences with stimulation of physiological self-healing, the active contribution to one’s own health, the doctor-patient relationship,
and the interactional style of the healthcare professional.
Previous research on the Consumer Quality Index has
demonstrated the importance of the doctor-patient relationship and communication. Patients’ global rating of their
healthcare is strongly determined by their experiences with
interpersonal aspects of care and doctor-patient communication [34]. By adding these aspects the CQ-Index AH
enhances the CQ-Index structure and extends the theory of
client experiences with healthcare in general.
The factor analyses demonstrate that the items regarding self-management in combination with other anthroposophic treatment items make a good independent
Table 5 New scales
Scale
Items
Mean scale score
Conbach’s alpha
InteractionalStyleGP
43. Making comfortable
3.6
0.810
3.1
0.832
44. Showing understanding
45. Providing insight in background and causes
48. Providing needed care
49. Balanced attitude
AnthroposophicTreatment
68. AH treatment options
69. Free choice of treatment options
73. Focus on physiological self-healing
75. Patients’ own responsibility
76. Patients’ active contribution
78. Giving meaning within daily life
84. Influence on quality of life
Koster et al. BMC Health Services Research 2014, 14:148
http://www.biomedcentral.com/1472-6963/14/148
Table 6 Pearson’s correlations between existing and new
anthroposophic scales
Interactional
style GP
Anthroposophic
treatment
Accessibility
.32*
.24*
Reception
.38*
.26*
SocialHandlingGP
.70*
.36*
CommunicationGP
.75*
.41*
TailoredCareGP
.76*
.56*
InteractionalStyleGP
1
.50*
Existing scales GP
* p < 0.05.
scale. The correlation of this scale (AnthroposophicTreatment) with all other GP-scales is small to moderate. The highest correlation of both new scales is found
with the scale TayloredCare (AnthroposophicTreatment:
r = 0, 56; p < 0, 05 and InteractionalStyleGP r = 0, 76; p <
0, 05). There is also a high correlation between InteractionalStyleGP and resp. SocialHandlingGP (r = 0, 70; p <
0, 05) and CommunicationGP (r = 0, 75; p < 0, 05).
These correlations demonstrate that the anthroposophic
aspects of care are relatively strongly related to individually tailored care and a social handling focussed on having
an alliance with the individual human being. Patients especially value this treatment attitude or interactional style.
This is an important reason why the scale InteractionalStyleGP is maintained, despite its high correlation with
these three scales. Further research needs to be done
among a patient population of both anthroposophic and
conventional GP’s to determine if and how these scales
can be integrated in order to reduce the amount of items.
The rating of the anthroposophic GPs is slightly higher
than the mean rating of the conventional GPs (8, 2) measured in 2008 [15] and 0, 5 point higher than the mean
rating of GPs in 2010 (7, 9) [13]. To illustrate: other mean
ratings are (for example): Asthma care: 7, 0 [12] Physiotherapist: 8, 0, Hospital specialist: 7, 7 [13] and COPD
care: 7, 7 [14]
Since the anthroposophic aspects are part of a broader
approach to practicing healthcare, emerging in the
current developments of self-management, tailored care
and health promotion it would be interesting to measure
the anthroposophic items in conventional GP practices.
Limitations
One of the limitations of this study regards the general response. Compared to the pilot study in 2008 the response
was again lower than expected. The recommendations
from this previous study to invite only the people who
have been to their GP in the last year and only people
from 18 years and older have not led to a higher response.
Page 11 of 12
Another limitation of this study is the discriminating
ability of the instrument. The small though statistically
significant discriminating ability enables this instrument of
measuring differences between practices, although possibly large samples are needed. Supplemented research
about the size of these samples is recommended here. Its
discriminating ability might be higher and more relevant if
tested among conventional and anthroposophic practices
together. However, the expectations should not be too
high, because the discriminative ability of patient experience surveys is sometimes rather limited [35].
Future perspectives
With the development of the CQ-Index AH there is a
standardized and validated instrument to measure patient experiences within the AH systematically and take
account of the quality of AH from the patients’ perspective. The future perspectives of this instrument are the
possibility of comparing anthroposophic institutes and
groups of professionals, meeting future criteria regarding
monitoring and assuring the quality of healthcare, and
the possibility of benchmarking within general and
anthroposophic healthcare. The recommendations of
this study are further research of the discriminating ability of the CQ-index AH and testing of the new scales
among non-AH populations in order to investigate and
compare the prevalence of a broader way of practicing
healthcare among other GP practices.
Conclusion
The CQ-index AH measures patient experiences within
AH validly and reliably. The quality of AH in the
Netherlands is good. The CQ-index AH enables AH to
take account of the quality of healthcare from the patients’
perspective systematically and in a standardized way. This
is of great importance for the future perspectives of AH.
Endnote
a
University of applied sciences.
Additional file
Additional file 1: CQIndex AH GP, CQIndex AH GP Validaded 2012.
pdf, Full questionnaire.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
EK conducted the study, performed analyses and drafted the manuscript. RO
performed analyses, was involved in the interpretation of findings and drafting
the manuscript, RH was involved with the data collection, DD was involved in
the interpretation of findings and critically revised the manuscript, EB
participated in the design of the study, supervised the study and critically
revised the manuscript. All authors read and approved the final version.
Koster et al. BMC Health Services Research 2014, 14:148
http://www.biomedcentral.com/1472-6963/14/148
Acknowledgments
The authors would like to thank the organisations and individuals that
funded the collection of the data, the patient organisation Antroposana, the
Iona Foundation, the Bernard Lievegoed Foundation, Laurine van Hoëvell
and the former patient organisation Hesperis.
The funding organisations had no role in the interpretation of the data and
in the preparation, review or approval of the manuscript.
Author details
1
Professorship Anthroposophic Healthcare, University of Applied Sciences
Leiden, Zernikedreef 11, Leiden 2333 CK, The Netherlands. 2Scientific Centre
for Transformation in Care and Welfare (Tranzo), Tilburg University, Tilburg,
The Netherlands.
Received: 15 May 2013 Accepted: 25 March 2014
Published: 2 April 2014
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doi:10.1186/1472-6963-14-148
Cite this article as: Koster et al.: The consumer quality index
anthroposophic healthcare: a construction and validation study. BMC
Health Services Research 2014 14:148.
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